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State of West Virginia Recredentialing Form:  Misrepresentation of any statements and information provided by you in support of this application shall be considered fraudulent and may result in denial or revocation of appointment.  (If more space is needed, please supply the information on a separate sheet and attach.)

5.State License(s):  List all current professional licenses   (Submit copy of current licenses)

State

License #

Issue Date

Expiration Date

Status

(Please check)

Is/was license restricted?

Reason License is/was Inactive or Restricted

 Active    

 Inactive

 Yes

 No

 Active    

 Inactive

 Yes

 No

 Active    

 Inactive

 Yes

 No

 Active    

 Inactive

 Yes

 No

 Active    

 Inactive

 Yes

 No

Does the scope of your practice require the supervision of another practitioner?

Yes No

If Yes, please list name of each supervising practitioner:

Practitioner Name:

6.Certifications/Registrations

Check here if entire section is not applicable to applicant or if no changes since last credentialing date.

Federal DEA Certificate

Not applicable

(Submit copy of current DEA Certificate)

Certificate #

Expiration Date

Unlimited?

Yes NoIf no, explain:  

State DEA or CDS Certificate(s)

Not applicable

(Submit copy of current State Controlled Dangerous Substance Certificates, if applicable)

Certificate #

Expiration Date

Unlimited?

Yes NoIf no, explain:  

Other Certificate(s)/Formal Training

(Please check below if currently certified.  Submit copy(s))

 Basic Life Support (BLS)

 Advanced Cardiac Life Support (ACLS)

 Pediatric Advanced Life Support (PALS)

 Advanced Trauma Life Support (ATLS)

 Neonatal Advanced Life Support (NALS)

 Anesthesia Permit

 Health Care Practitioner (Core C)

 Neonatal Resuscitation Program (NRP)

 Therapeutics Classification Number (Optometrists only)

 Other (please list below or on a separate sheet and include descriptions):

12/02; 3/03; 11/03; 1/04; 5/04; 10/04     **Confidential and Privileged Peer Review Pursuant to WV Code 30-3C-1 et.seq** Page 7

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